Frailty

Frailty is often the final stage of life
and needs to be recognised and managed appropriately.

L de
Villiers, MB
ChB (Cape Town), FCP SA

Senior specialist in
the Division of Geriatric Medicine, Institute of Ageing in
Africa, University of Cape Town, Cape Town, South Africa

Corresponding
author: L de Villiers
(linda.devilliers@uct.ac.za)

Clinicians recognise frailty as a state of ‘weakness’ where
there is an increased vulnerability to adverse outcomes and
where minor physiological stressors can lead to progressive
deterioration. In the frail elderly, each insult results in
functional decline which does not recover to prior levels
(Fig.1).

Fig. 1. The progression of frailty.

Frailty may be primary or secondary to
medical conditions and the challenge in assessing and managing
frail persons is to understand the complex relationships
between frailty, disability and co-morbidity; and in so doing,
to improve function, overcome environmental and morbidity
challenges and keep elderly people in their communities by
preventing institutionalisation. There are many definitions of
frailty, of which that described by Freid et al. from data collected in the Women’s Health
and Aging Studies is possibly
the most useful clinically (Fig. 2).1 Frailty is associated with cognitive
impairment, depression, social isolation, incontinence,
osteoporosis, osteoarthritis and atherosclerosis and multiple
contributing factors such as malnutrition, reduced physical
activity and medication side-effects, which interact to result
in falls, hospital admissions, functional decline and
institutionalisation and perpetuate the spiral of increasing
frailty.

According to Freid et al. frailty is at least 3 of the following:

• loss of weight (> 5% body weight or
4.5 kg over 1 year)

• slow walking speed (>7 seconds over
5 m)

• exhaustion CESD-D depression scale

• reduced physical
activity (<383 kcal/week)

• Reduced grip strength.

The prevalence of frailty increases with
age from 7% in those aged 65 years to over 20% in those over
80 years of age. 2 The loss of reserve capacity, as well as
unstable homeostasis, and then function in multiple
physiological systems such as muscle (sarcopaenia),
neurological (increased postural sway and impaired postural
reflexes), cardiovascular (postural hypotension) and water and
electrolyte balance, lead to a state of ‘weakness’, which
results in an increased risk of falls, incontinence, delirium,
hospitalisation, institutionalisation and death.

Physiological changes in the very old,
which include hormonal, hypothalamic-pituitary axis and
inflammatory changes, predispose them to progressive frailty.
Oestrogen in women and testosterone, to a lesser extent, in
men decline with age. Oestrogen suppresses IL-6 which,
together with C-reactive protein and TNFα are raised in the
frail elderly and contribute to activation of the clotting
cascade with increased factor VII, fibrinogen and D-dimers
leading to adverse vascular outcomes.3 Endocrine changes also contribute to the
accelerated loss of muscle mass seen in frailty. Lower levels
of growth hormone, dehydroepiandrosterone sulphate,
insulin-like growth factor-1 (IGF-1) and increased cortisol
are seen.4 These age-associated changes in physiology
lead to primary frailty and increasing vulnerability to
physical and functional decline as a result of minor physical
or psychosocial stressors (Fig. 2).

Fig. 2. Age-associated changes in
physiology and their consequences.

Assessing and managing frailty requires a multidisciplinary
approach involving medical, rehabilitation, social and dietary
interventions. The task of the physician is:

1. to prevent frailty in community-dwelling elderly

2. to intervene after an acute insult to restore function

3. to assess and manage as soon as frailty is recognised

4. to optimise function and quality of life with increasing
frailty.

Preventing frailty in the community-dwelling elderly

Medical care of functional
community-dwelling older persons should focus on optimising
management of vascular risk factors and chronic diseases while
critically reviewing medication to prevent iatrogenesis from
side-effects, which increase with the number of prescribed and
over-the-counter medications taken. Side-effects such as
postural hypotension from anti-hypertensives, dizziness,
myopathy from statins and poor appetite should be screened
for. Drugs which increase the risk of falls, such as
psychotropics, especially benzodiazepines and those with
anticholinergic side-effects, should be avoided. Assessment
for emerging physical impairments, such as loss of hearing and
vision, postural instability (get-up-and-go test) and
incontinence, should form part of routine follow-up. Atrophic
vaginitis contributes to urinary urgency and management with
topical oestrogen is effective. In order to maintain an active
lifestyle, management of osteoporosis and pain from
osteoarthritis should be optimised.

Lifestyle advice should include exercise and dietary advice.
Exercise should include both aerobic exercise and activities
that maintain strength and postural control. Practical advice is
brisk walking at least 30 minutes 4 times a week and an exercise
where static balance and strength is improved such as
calinetics, Thai Chi or Rekei. Increasing energy expenditure
also improves appetite. The diet should be adequate in protein,
vitamins and minerals and overly restrictive diets should be
avoided. Care should be taken to avoid medication which
suppresses appetite, saliva or taste, and good dental care
prevents oral problems.

Intervene after an acute insult to restore
function

When an acute illness or insult such as
a fall, infection or surgery occurs, physical inactivity and
under-nutrition combined with a catabolic state can result in
rapid deconditioning and loss of muscle mass and strength.
Poor nutrition is common in hospitalised patients and
supplements of protein and calories (such as shakes) can
prevent this. Patients should be mobilised as soon as possible
and exercised in bed until then. Physiotherapy should be
initiated as soon as the patient is admitted and
rehabilitation continued until baseline function has been
achieved. An occupational therapy assessment should be
performed before discharge. Care needs to be taken to prevent
factors which contribute to delirium, such as dehydration,
faecal impaction, uncontrolled pain and drugs. Functional
incontinence is common and can be avoided by timed toileting
and the use of bulking agents and suppositories to prevent
constipation. Urinary catheters should be avoided if possible
and, if not, clamping and releasing can prevent the onset of
urge incontinence when the catheter is removed. 5

Assess and manage as soon as frailty is
recognised

Once frailty has led to significant
physical and functional decline it is difficult to reverse.
For that reason persons at risk of becoming frail or where the
onset of frailty is recognised should have a comprehensive
geriatric assessment, which includes assessment and optimising
management of chronic and degenerative diseases, looking for
the onset of new diseases, which may be precipitating frailty,
screening for cognitive decline and depression, nutritional
assess­ment, screening for sensory impair­ments, gait and
balance assessment, environmental assessment and assessing the
adequacy of social support. 6

The medical assessment

Systemic enquiry needs to be comprehensive, covering cognitive
function, symptoms of depression, impairments in balance, falls
or fear of falling, bladder and bowel function and sensory
impairments in addition to the major physiological systems. The
examination includes supine and erect blood pressure at 1 and 3
minutes to identify postural hypotension and an ECG and chest
X-ray to identify cardiorespiratory pathologies contributing to
‘exhaustion’. Thorough neurological and musculoskeletal
examination, including foot problems, is indicated if abnormal
gait or postural control if observed on the gait and balance
assessment.

Gait and balance assessment

The value of assessing gait and balance
is that not only can one identify and assess the severity of
age-related impairment in postural control, but when there are
pathologies, often multiple, a functional assessment can be
conducted in a few minutes to identify which pathology is
implicated. More detailed assessment can be conducted by a
physiotherapist if required.

Get-up-and-go test

The person sits in a chair without arms where the knees are at
90° and gets up without using their arms, walks 3 m, turns 180°
walks back and sits down. The test can be timed to achieve
better predictive results and rated as follows:

• <10 seconds: freely mobile

• <20 seconds: mostly independent

• 20 - 30 seconds: variable mobility

• >30 seconds: impaired mobility.

Difficulty on sit-to-stand indicates hip and thigh weakness,
which is common with sarcopaenia and deconditioning as well as
myopathies. Swaying and using arms to steady indicates poor
postural control. The gait of frailty and fear of falling is
small steps, poor foot clearance, mildly wide base and forward
flexed posture. One could also identify common pathologies
affecting gait in the elderly such as Parkinson’s, spastic gait
from cervical myelopathies, hemiparetic gait or antalgic gait
from lower extremity osteoarthritis, gout or foot problems.
Milder impairments in postural control or fear of falling will
result in the taking of more than 3 steps, shuffling or
staggering when executing a 180° turn.

Fig. 3. The get-up-and-go test.

Romberg’s test

The person stands with feet together and then closes the eyes
for at least 15 seconds. The person then has to rely on
vestibular function and proprioreceptive sensation alone to
maintain balance. If staggering or taking a step occurs to
prevent falling there is sensory or vestibular impairment. Look
also for for backward and forward swaying (postural sway), which
indicates slow postural reflexes and increased risk of falls.

Fig. 4. The Romberg test.

Sternal nudge

While standing with the feet together and the eyes open the
examiner gently nudges the patient on the sternum with 2
fingers, hard enough for the patient to offer some resistance to
keep their posture. The examiner should keep their other hand
behind the patient's back to prevent them from falling should
they lose their balance. Excessive swaying, losing balance or
taking a step backwards indicates poor postural control.

Impaired postural control, along with
reduced core and proximal muscle strength, are the primary
causes of gait instability and fear of falling which leads to
the person adopting the gait and posture common in frailty –
slightly wide-based, small steps and shuffling with poor heal
strike. The person leans forward with the head extended, thus
altering the center of gravity and further increasing the risk
of falls.7

Screening for malignancy is part of the
routine clinical examination that should include examination
of the thyroid, breast, prostate, rectum and gynecological
examination as well as an occult blood. The medical assessment
may find that existing pathologies, such as advanced cardiac,
respiratory, neurodegenerative or malignant conditions may be
sufficient to explain the progression of frailty. If this is
not the case, symptoms or signs may be identified that point
to a new pathology, which should be investigated in its own
right. The problem is that pathologies common in the elderly
may present with few specific signs and symptoms to guide the
clinician, and exhaustive investigation is expensive and
rarely rewarding. The difficulty in the very old is that
increasing frailty may be the only manifestation of a new
pathology. Choosing an appropriate spectrum of investigations
which will identify pathologies common in the elderly or
which, if abnormal, will identify the need for further
investigation, depends on the resources available.8,9

Once the medical assessment is completed, the clinician should
have excluded or identified new pathologies, optimised
management of chronic diseases and decided if impairments
leading to disability can be improved, are stable or will
continue to deteriorate. When there is physical frailty, even in
the presence of progressive degenerative disease, physical
rehabilitation can improve both endurance and strength and
postural control. Good communication between the physician and
rehabilitation teams are needed to define realistic goals for
functional outcomes and their impact on the patients’
independence in ADLs and IADLs. Impairments and subsequent
disability in the frail may be improved, but seldom reversed,
and functional limitations need to be addressed to improve
independence. Altering the frail person’s physical environment
in order to improve independence is the domain of the
occupational therapist, who needs to work closely with the
physiotherapist in order to identify functional goals and adapt
the environment where physical impairments that limit
independence are likely to remain.

With frailty, physical and functional impairments are likely to
remain and, depending on the co-morbidities present, deteriorate
with time, resulting in increasing care needs. Assessing the
social, physical and financial support available to the frail
person is important in deciding if it is adequate and
sustainable, and if not, engaging social services and planning
for long-term care needs. Caregiver burden and stress should be
assessed to identify where support is needed.
Institutionalisation may be the only option where support is
inadequate or not sustainable. In this case the kind of
institution and the level of care provided should be adequate
for the person’s functional limitations, but provide scope for
independence in domains where they can function.

Fig. 5. Suggested baseline
investigations.

Managing chronic frailty

When frailty is established and
functional limitations cannot be regained or are likely to
progress the goal of management is to retain function and
independence as long as possible,and to
minimise the person’s vulnerability to further decline. The
physician’s role is to optimise management of chronic
diseases, paying particular attention to conditions impairing
cognition, mobility and continence, and to ensure that
medication side-effects and interactions are not contributing
to impairments or impairing quality of life. Symptoms such as
confusion, dizziness, postural hypotension, constipation and
urinary urgency are commonly drug- related. Constipation is a
common problem in frail persons who are physically inactive
and faecal impaction leads not only to faecal and urinary
overflow incontinence, but also to poor nutritional intake and
delirium.

Nutrition is often poor for a variety of
reasons, such as reduced taste, cognitive impairment,
depression, dental problems, inability to cook or financial
constraints. Ensuring good protein and vitamin intake is
essential to minimise the progression of sarcopaenia. Exercise
is important, not only in maintaining muscle strength and
balance, but increased energy expenditure improves appetite
and well-being. Even in the very frail, exercise and
nutritional interventions have shown benefit.10
In frail patients with co-morbidities,
which may include cardiorespiratory, neurological and
musculoskeletal diseases, individualised exercise programmes
may be needed. Vitamin D is necessary to prevent osteo­porosis
and for muscle function. Routine supplementation is
controversial, but given that frail persons often have limited
sun exposure and are at risk of deficiency, this is a common
practice.11,12

Occupational therapists have an ongoing
role in optimising function and independence of the person and
by adapting the environment. As dependency and care needs
increase, the adequacy of social, physical and financial
support should be monitored.

Summary

• Multiple factors contribute,
such as malnutrition, reduced physical activity and medication
side effects, which interact to result in falls, hospital
admissions, functional decline and institutionalisation and
perpetuate the spiral of increasing frailty

• When frailty is established
and functional limitations cannot be regained or are likely to
progress, the goal of management is to retain function and
independence as long as possible and to minimise the person’s
vulnerability to further decline